Provider Demographics
NPI:1063870723
Name:KIM, EDWARD J (PA)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:J
Last Name:KIM
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:9888 GENESEE AVE
Mailing Address - Street 2:TRAUMA SERVICE #LJ601
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037
Mailing Address - Country:US
Mailing Address - Phone:858-626-6362
Mailing Address - Fax:
Practice Address - Street 1:9888 GENESEE AVE
Practice Address - Street 2:TRAUMA SERVICE #LJ601
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037
Practice Address - Country:US
Practice Address - Phone:858-626-6362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-09
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA52796363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant